Measure Submission and Evaluation Worksheet 5.0

Transcription

1 NATIONAL QUALITY FORUM Measure Submission and Evaluation Worksheet 5.0 This form contains the information submitted by measure developers/stewards, organized according to NQF s measure evaluation criteria and process. The evaluation criteria, evaluation guidance documents, and a blank online submission form are available on the submitting standards web page. NQF #: 0646 NQF Project: Care Coordination Project (for Endorsement Maintenance Review) Original Endorsement Date: May 05, 2010 Most Recent Endorsement Date: May 05, 2010 BRIEF MEASURE INFORMATION De.1 Measure Title: Reconciled Medication List Received by Discharged Patients (Discharges from an Inpatient Facility to Co.1.1 Measure Steward: American Medical Association - Physician Consortium for Performance Improvement De.2 Brief Description of Measure: Percentage of patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, or their caregiver(s), who received a reconciled medication list at the time of discharge including, at a minimum, medications in the specified categories 2a1.1 Numerator Statement: Patients or their caregiver(s) who received a reconciled medication list at the time of discharge including, at a minimum, medications in the following categories: Medications to be TAKEN by patient: - Continued* Medications prescribed before inpatient stay that patient should continue to take after discharge, including any change in dosage or directions AND - New* Medications started during inpatient stay that are to be continued after discharge and newly prescribed medications that patient should begin taking after discharge * Prescribed dosage, instructions, and intended duration must be included for each continued and new medication listed Medications NOT to be Taken by patient: - Discontinued Medications taken by patient before the inpatient stay that should be discontinued or held after discharge, AND - Allergies and Adverse Reactions Medications administered during the inpatient stay that caused an allergic reaction or adverse event and were therefore discontinued 2a1.4 Denominator Statement: All patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care. Time Window: Each time a patient is discharged from an inpatient facility 2a1.8 Denominator Exclusions: Patients who died Patients who left against medical advice (AMA) or discontinued care 1.1 Measure Type: Process 2a Data Source: Administrative claims, Electronic Clinical Data : Electronic Health Record, Paper Records 2a1.33 Level of Analysis: Facility, Integrated Delivery System Is this measure paired with another measure? No See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 1

2 De.3 If included in a composite, please identify the composite measure (title and NQF number if endorsed): Comments on Conditions for Consideration: STAFF NOTES (issues or questions regarding any criteria) Is the measure untested? Yes No If untested, explain how it meets criteria for consideration for time-limited endorsement: 1a. Specific national health goal/priority identified by DHHS or NPP addressed by the measure (check De.5): 5. Similar/related endorsed or submitted measures (check 5.1): Other Criteria: Staff Reviewer Name(s): 1. IMPACT, OPPORTUITY, EVIDENCE - IMPORTANCE TO MEASURE AND REPORT Importance to Measure and Report is a threshold criterion that must be met in order to recommend a measure for endorsement. All three subcriteria must be met to pass this criterion. See guidance on evidence. Measures must be judged to be important to measure and report in order to be evaluated against the remaining criteria. (evaluation criteria) 1a. High Impact: H M L I (The measure directly addresses a specific national health goal/priority identified by DHHS or NPP, or some other high impact aspect of healthcare.) De.4 Subject/Topic Areas (Check all the areas that apply): De.5 Cross Cutting Areas (Check all the areas that apply): Care Coordination, Safety, Safety : Medication Safety 1a.1 Demonstrated High Impact Aspect of Healthcare: Affects large numbers, Patient/societal consequences of poor quality 1a.2 If Other, please describe: 1a.3 Summary of Evidence of High Impact (Provide epidemiologic or resource use data): Incidence and Prevalence: A study by Coleman and colleagues tracked post-hospital transitions for 30 days in a large, nationally representative sample of Medicare beneficiaries. Transitions in this study were defined as transfers to or from an acute hospital, skilled nursing or rehabilitation facility, or home with or without home health care. Between 12 and 25 percent of all care patterns were categorized as complicated, requiring return to higher intensity care settings. Overall, 46 unique care patterns were identified during the 30-day time period. Sixty-one percent of care episodes resulted in one transition, 18 percent in 2 transitions, 9 percent in 3 transitions, 4 percent in 4 or more transitions, and 8 percent resulted in death. Twenty-three percent of hospitalized patients over the age of 65 are discharged to another institution, and 11.6 percent are discharged with home health care. An estimated 19 percent of patients discharged from a hospital to a skilled nursing facility (SNF) are readmitted to the hospital within 30 days. Transfers from nursing homes to acute-care hospitals comprise 8.5 percent of all Medicare admissions to acute-care hospitals; about 40 percent of these hospitalizations occur within 90 days of nursing home admission. Eighty-four percent of these patients are discharged from the hospital back to their nursing home of origin. Jack and colleagues conducted a randomized trial of 749 discharged patients. A nurse discharge advocate worked with See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 2

3 368 patients to arranged follow up appointments, confirm medication reconciliation, and conduct patient education via a take home booklet. The patients also received a call from a clinical pharmacist 2 to 4 days after discharge to reinforce the discharge plan and review medications. This patient population had a 30 percent decrease in hospital utilization 30 days after discharge, reported a higher degree of preparedness for discharge and had higher rates of PCP follow up within 30 days of discharge. Cost In 2006, there were over 39 million hospital discharges; of those, 13 percent of these patients are repeatedly hospitalized and use 60 percent of the healthcare resources. A 2007 report by the Medicare Payment Advisory Commission estimated approximately 18 percent of admissions result in readmissions within 30 days, costing CMS $15 billion. The Institute of Medicine estimated that medication errors harm 1.5 million people each year in the United States, at an annual cost of at least $3.5 billion. Gaps in Care: Sabogal and colleagues found that uncoordinated transitions between sites of care, even within the same institution, and between caregivers increase hospital readmissions, medical errors, duplication of services, and waste of resources. Moore and colleagues examined three types of discontinuity of care among older patients transferred from the hospital: medication, test result follow-up, and initiation of a recommended work-up. They found that nearly 50 percent of hospitalized patients experienced at least one discontinuity and that patients who did not have a recommended work-up initiated were six times more likely to be re-hospitalized. Medication errors An estimated 60 percent of medication errors occur during times of transition: upon admission, transfer, or discharge of a patient. During care transitions, patients receive medications from different prescribers who rarely have access to patients comprehensive medication list. Forster and colleagues found that 19 percent of discharged patients experienced an associated adverse event within three weeks of leaving the hospital; 66 percent of these were adverse drug events. An observational study by Coleman and colleagues showed that 14 percent of elderly patients had one or more medication discrepancies and that, within that group of patients, 14 percent were re-hospitalized at 30 days compared to 6 percent of the patients who did not experience a medication discrepancy. 1a.4 Citations for Evidence of High Impact cited in 1a.3: Coleman EA, Min S, Chomiak A, Kramer AM Post-hospital care transitions: patterns, complications, and risk identification. Health Services Research 39: Agency for Healthcare Research and Quality (ARHQ) Outcomes by Patient and Hospital Characteristics for All Discharges. Available at: Kramer A, Eilertsen T, Lin M, Hutt E Effects of nurse staffing on hospital transfer quality measures for new admissions. Pp Inappropriateness of Minimum Nurse Staffing Ratios for Nursing Homes. Health Care Financing Administration. Hutt E, Ecord M, Eilertsen TB, et al. Precipitants of emergency room visits and acute hospitalization in short-stay Medicare nursing home residents. J Am Geriatr Soc 2001; 50: Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Ann Intern Med 2009; 150: Agency for Healthcare Research and Quality (ARHQ) Outcomes by Patient and Hospital Characteristics for All Discharges. Available at: See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 3

4 Medicare Payment Advisory Commission. A data book: Healthcare spending and the medicare program. June Available at: Harris G. Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006). Available at: emc=rss. Sabogal F, Coots-Miyazaki M, Lett JE. Effective care transitions interventions: Improving patient safety and healthcare quality. CAHQ Journal 2007 (Quarter 2). Moore C, Wisnevesky J, Williams S, McGinn T Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine 18: Rozich JD & Resar, RK Medication safety: One organization s approach to the challenge. J. Clin. Outcomes Manag. 8: Partnership for Solutions Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138(3): Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 2005;165(16): b. Opportunity for Improvement: H M L I (There is a demonstrated performance gap - variability or overall less than optimal performance) 1b.1 Briefly explain the benefits (improvements in quality) envisioned by use of this measure: The Institute of Medicine estimated that medication errors harm 1.5 million people each year in the United States, at an annual cost of at least $3.5 billion. Many of these medication errors (approximately 60% in one study) occur during times of transition, when patients receive medications from different prescribers who lack access to patients comprehensive medication list. Providing patients with a comprehensive, reconciled medication list at each care transition (eg, inpatient discharge) may improve patients ability to manage their medication regimen properly and reduce the number of medication errors. A recent study in Sweden found that providing elderly patients with a structured, comprehensive summary of their medications at discharge significantly reduced the risk of adverse clinical consequences due to medication errors. Preventable adverse events from medication errors affect approximately 2 out of every 100 patients admitted to the hospital, and adverse events outside the hospital are estimated to account for 4.7 percent of hospital admissions. [Leape, 1994; Kanjanarat, 2003; Lazarou, 1998] Effective preventability strategies for the reduction of medication errors and subsequent ADEs have been found through successful medication reconciliation processes. [Nickerson, 2005; Bartick, 2006; Boockvar, 2006; Vira, 2006] The Care Transitions Work Group has identified several indicators of success in improving outcomes for patients undergoing transitions in care, including: 1. Reduction in adverse drug events 2. Reduction in patient harm related to medical errors of omission and commission 3. Reduction in unnecessary healthcare encounters (eg, hospital readmissions) 4. Reduction in redundant tests and procedures 5. Achievement of patient goals and preferences (eg, functional status, comfort care) 6. Improved patient understanding of and adherence to treatment plan Citations: Harris G. Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006). Available at: emc=rss. Rozich JD & Resar, RK Medication safety: One organization s approach to the challenge. J. Clin. Outcomes Manag. 8: Partnership for Solutions Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University. Midlöv P et. al. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Pharm See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 4

5 World Sci. 2008;30: Leape LL. Error in medicine. JAMA 1994 Dec 21;272(23): Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003 Sep 1;60(17): Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998 Apr 15;279(15): Nickerson A, MacKinnon NJ, Roberts N, et al. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q 2005;8 Spec No: Available at Last accessed October 8, Bartick M, Baron D. Medication reconciliation at Cambridge Health Alliance: experiences of a 3-campus health system in Massachusetts. Am J Med Qual 2006 SepOct;21(5): Boockvar KS, Carlson LaCorte H, Giambanco V, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 2006 Sep;4(3): Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006 Apr;15(2): Available at picrender.fcgi?artid= &blobtype=pdf. Last accessed October 8, b.2 Summary of Data Demonstrating Performance Gap (Variation or overall less than optimal performance across providers): [For Maintenance Descriptive statistics for performance results for this measure - distribution of scores for measured entities by quartile/decile, mean, median, SD, min, max, etc.] An observational study by Coleman and colleagues showed that 14% of elderly patients had one or more medication discrepancies and that, within that group of patients, 14% were re-hospitalized at 30 days compared to 6% of the patients who did not experience a medication discrepancy. A study by Forster and colleagues found that 19 percent of discharged patients experienced an associated adverse event within three weeks of leaving the hospital; 66 percent of these were adverse drug events. Gaps in Care: Sabogal and colleagues found that uncoordinated transitions between sites of care, even within the same institution, and between caregivers increase hospital readmissions, medical errors, duplication of services, and waste of resources. Moore and colleagues examined three types of discontinuity of care among older patients transferred from the hospital: medication, test result follow-up, and initiation of a recommended work-up. They found that nearly 50 percent of hospitalized patients experienced at least one discontinuity and that patients who did not have a recommended work-up initiated were six times more likely to be re-hospitalized. Medication errors An estimated 60 percent of medication errors occur during times of transition: upon admission, transfer, or discharge of a patient. During care transitions, patients receive medications from different prescribers who rarely have access to patients comprehensive medication list. Preventable adverse events from medication errors affect approximately 2 out of every 100 patients admitted to the hospital, and adverse events outside the hospital are estimated to account for 4.7 percent of hospital admissions. [Leape, 1994; Kanjanarat, 2003; Lazarou, 1998] Effective preventability strategies for the reduction of medication errors and subsequent ADEs have been found through successful medication reconciliation processes. [Nickerson, 2005; Bartick, 2006; Boockvar, 2006; Vira, 2006] 1b.3 Citations for Data on Performance Gap: [For Maintenance Description of the data or sample for measure results reported in 1b.2 including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included] Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 5

6 Med 2005;165(16): Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138(3): Sabogal F, Coots-Miyazaki M, Lett JE. Effective care transitions interventions: Improving patient safety and healthcare quality. CAHQ Journal 2007 (Quarter 2). Moore C, Wisnevesky J, Williams S, McGinn T Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine 18: Rozich JD & Resar, RK Medication safety: One organization s approach to the challenge. J. Clin. Outcomes Manag. 8: Partnership for Solutions Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University. Leape LL. Error in medicine. JAMA 1994 Dec 21;272(23): Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003 Sep 1;60(17): Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998 Apr 15;279(15): Nickerson A, MacKinnon NJ, Roberts N, et al. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q 2005;8 Spec No: Available at Last accessed October 8, Bartick M, Baron D. Medication reconciliation at Cambridge Health Alliance: experiences of a 3-campus health system in Massachusetts. Am J Med Qual 2006 SepOct;21(5): Boockvar KS, Carlson LaCorte H, Giambanco V, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 2006 Sep;4(3): Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006 Apr;15(2): Available at picrender.fcgi?artid= &blobtype=pdf. Last accessed October 8, b.4 Summary of Data on Disparities by Population Group: [For Maintenance Descriptive statistics for performance results for this measure by population group] We are not aware of any publications or evidence outlining disparities in this area. 1b.5 Citations for Data on Disparities Cited in 1b.4: [For Maintenance Description of the data or sample for measure results reported in 1b.4 including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included] N/A 1c. Evidence (Measure focus is a health outcome OR meets the criteria for quantity, quality, consistency of the body of evidence.) Is the measure focus a health outcome? Yes No If not a health outcome, rate the body of evidence. Quantity: H M L I Quality: H M L I Consistency: H M L I Quantity Quality M-H M-H M-H Yes Consistency Does the measure pass subcriterion1c? L M-H M Yes IF additional research unlikely to change conclusion that benefits to patients outweigh harms: otherwise No M-H L M-H Yes IF potential benefits to patients clearly outweigh potential harms: otherwise No L-M-H L-M-H L No Health outcome rationale supports relationship to at least one healthcare structure, process, intervention, or service Does the measure pass subcriterion1c? Yes IF rationale supports relationship 1c.1 Structure-Process-Outcome Relationship (Briefly state the measure focus, e.g., health outcome, intermediate clinical outcome, process, structure; then identify the appropriate links, e.g., structure-process-health outcome; process- health outcome; See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 6

7 intermediate clinical outcome-health outcome): The measure focus is the process of providing a reconciled medication list to patients at the time of discharge from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care. This process is directly related to preventing medication errors, adverse drug events, patient harm, and hospital readmissions. The Institute of Medicine estimated that medication errors harm 1.5 million people each year in the United States, at an annual cost of at least $3.5 billion. Many of these medication errors (approximately 60% in one study) occur during times of transition, when patients receive medications from different prescribers who lack access to patients comprehensive medication list. Providing patients with a comprehensive, reconciled medication list at each care transition (eg, inpatient discharge) may improve patients ability to manage their medication regimen properly and reduce the number of medication errors. A recent study in Sweden found that providing elderly patients with a structured, comprehensive summary of their medications at discharge significantly reduced the risk of adverse clinical consequences due to medication errors. Preventable adverse events from medication errors affect approximately 2 out of every 100 patients admitted to the hospital, and adverse events outside the hospital are estimated to account for 4.7 percent of hospital admissions. [Leape, 1994; Kanjanarat, 2003; Lazarou, 1998] Effective preventability strategies for the reduction of medication errors and subsequent ADEs have been found through successful medication reconciliation processes. [Nickerson, 2005; Bartick, 2006; Boockvar, 2006; Vira, 2006] Citations: Harris G. Report finds a heavy toll from medication errors, N.Y. Times (July 21, 2006). Available at: emc=rss. Rozich JD & Resar, RK Medication safety: One organization s approach to the challenge. J. Clin. Outcomes Manag. 8: Partnership for Solutions Chronic Conditions: Making the Case for Ongoing Care. Baltimore MD: The Johns Hopkins University. Midlöv P et. al. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Pharm World Sci. 2008;30: Leape LL. Error in medicine. JAMA 1994 Dec 21;272(23): Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003 Sep 1;60(17): Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998 Apr 15;279(15): Nickerson A, MacKinnon NJ, Roberts N, et al. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q 2005;8 Spec No: Available at Last accessed October 8, Bartick M, Baron D. Medication reconciliation at Cambridge Health Alliance: experiences of a 3-campus health system in Massachusetts. Am J Med Qual 2006 SepOct;21(5): Boockvar KS, Carlson LaCorte H, Giambanco V, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 2006 Sep;4(3): Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006 Apr;15(2): Available at picrender.fcgi?artid= &blobtype=pdf. Last accessed October 8, c.2-3 Type of Evidence (Check all that apply): Clinical Practice Guideline, Systematic review of body of evidence (other than within guideline development) 1c.4 Directness of Evidence to the Specified Measure (State the central topic, population, and outcomes addressed in the body of evidence and identify any differences from the measure focus and measure target population): The evidence cited for this measure is directly related to medication reconciliation for all ages, during transitions of care from inpatient to outpatient settings. There are no differences from the measure focus and measure target population. See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 7

8 1c.5 Quantity of Studies in the Body of Evidence (Total number of studies, not articles): The quantity of studies reviewed was not stated, but the guideline paper references 21 articles. 1c.6 Quality of Body of Evidence (Summarize the certainty or confidence in the estimates of benefits and harms to patients across studies in the body of evidence resulting from study factors. Please address: a) study design/flaws; b) directness/indirectness of the evidence to this measure (e.g., interventions, comparisons, outcomes assessed, population included in the evidence); and c) imprecision/wide confidence intervals due to few patients or events): The quality of the evidence was not discussed; however, the guideline paper provided the following summary: Summary: This guideline is the result of a consensus conference convened in 2006 by the American College of Physicians (ACP), the Society of General Internal Medicine (SGIM), and the Society of Hospital Medicine (SHM), with representation from the Emergency Medicine community added subsequent to the conference. The participating organizations focused specifically on the development of principles and standards for transitions of care between the inpatient and outpatient settings, in preparation for the development of performance measures. The standards development of the Transitions of Care Consensus Conference (TOCCC) built upon the earlier work of the Stepping Up to the Plate (SUTTP) Alliance established by the ABIM Foundation. Guideline development methodology: The TOCCC developed its principles and standards based on a systematic review of the evidence related to transitions of care between the inpatient and outpatient settings. After initial discussion in breakout groups, the conference participants refined the principles and standards through a group consensus process. Participants then prioritized the standards using a group consensus voting process. The final summary paper was subsequently reviewed and approved by all participating organizations. Evidence base: The TOCCC developed 8 standards for care transitions, based on cohort, observational, and cross-sectional studies and expert opinion. The standards/ recommendations were developed and prioritized by a group consensus process. 1c.7 Consistency of Results across Studies (Summarize the consistency of the magnitude and direction of the effect): Again, the consistency of results across studies was not discussed, but the number of people and organizations involved in the development of the consensus statement suggest great consistency in the evidence base. The TOCCC was held over two days on July 11-12, 2007 at ACP Headquarters in Philadelphia, PA. There were 51 participants representing over thirty organizations. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies, such as the AHRQ and CMS, performance measure developers, such as the NCQA and AMA PCPI, nurses associations, such as the VNAA and Home Care and Hospice, pharmacists groups, and patient groups such as the Institute for Family-Centered Care. The TOCCC developed 8 standards for care transitions, based on cohort, observational, and cross-sectional studies and expert opinion. The standards/ recommendations were developed and prioritized by a group consensus process. In addition, multiple studies have consistently shown that successful medication reconciliation processes are effective preventability strategies for the reduction of medication errors and subsequent adverse drug events. [Nickerson, 2005; Bartick, 2006; Boockvar, 2006; Vira, 2006] 1c.8 Net Benefit (Provide estimates of effect for benefit/outcome; identify harms addressed and estimates of effect; and net benefit - benefit over harms): There are no potential harms discussed in this guideline or in the evidence, only the harm caused by not conducting medication reconciliation. The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between the many other different care settings such as hospital to nursing home, or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvement in quality and safety in care transitions. 1c.9 Grading of Strength/Quality of the Body of Evidence. Has the body of evidence been graded? No 1c.10 If body of evidence graded, identify the entity that graded the evidence including balance of representation and any disclosures regarding bias: N/A See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 8

9 1c.11 System Used for Grading the Body of Evidence: Other 1c.12 If other, identify and describe the grading scale with definitions: The body of evidence was not graded. 1c.13 Grade Assigned to the Body of Evidence: N/A 1c.14 Summary of Controversy/Contradictory Evidence: No areas of controversy. 1c.15 Citations for Evidence other than Guidelines(Guidelines addressed below): 1c.16 Quote verbatim, the specific guideline recommendation (Including guideline # and/or page #): The following evidence statements are quoted verbatim: Transition record All transitions must include a transition record. There is a minimal set of data elements that should always be part of the transition record: Principal diagnosis and problem list Medication list (reconciliation) including OTC/herbals, allergies and drug interactions Clearly identifies the medical home/transferring coordinating physician/institution and their contact information Patient s cognitive status Test results/pending results (TOCCC, 2009) Medication reconciliation Reconcile discharge orders with the nursing medication administration record: After discharge from the hospital, a patient may continue taking some medications at home, but not perhaps all of them. Therefore, it is extremely important to compare the discharge medication orders with the nursing medication administration record (MAR) to check for any discrepancies. If a medication the patient has been receiving in the hospital is not in the discharge orders, and there is no adequate documentation indicating why that medication has been omitted, then a nurse or pharmacist should contact the patient s physician to verify whether or not the patient should discontinue use of the medication. Create a standardized form that lists all the medications the patient has been receiving in the hospital, and include space on the form for physicians to document the reasons for omitting certain medications upon discharge from the hospital. Physicians can also use this form for ordering medications. Attach the pre-admission medication list to the discharge orders form the patient may need to discontinue some medications that were being taken at home. Provide the patient with a comprehensive list of all medications those being taken before admission plus the new medications from the discharge orders. Clearly indicate the name of each drug, its purpose, and the instructions for taking the medication, as well as any instructions for discontinuing use. (IHI) NPSG A process exists for comparing the [patient] s current medications with those ordered for the [patient] while under the care of the [organization]. 1. At the time the patient enters the hospital or is admitted, a complete list of the medications the patient is taking at home (including dose, route, and frequency) is created and documented. The patient and, as needed, the family are involved in creating this list. 2. The medications ordered for the patient while under the care of the hospital are compared to those on the list created at the time of entry to the hospital or admission. 3. Any discrepancies (that is, omissions, duplications, adjustments, deletions, additions) are reconciled and documented while the patient is under the care of the hospital. See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 9

10 4. When the patient s care is transferred within the hospital (for example, from the ICU to a floor), the current provider(s) informs the receiving provider(s) about the up-to-date reconciled medication list and documents the communication. (See also NPSG , EP 2) Note: Updating the status of a patient s medications is also an important component of all patient care hand-offs. (Joint Commission National Patient Safety Goals, 2009) NPSG When a [patient] is referred to or transferred from one [organization] to another, the complete and reconciled list of medications is communicated to the next provider of service, and the communication is documented. Alternatively, when a [patient] leaves the [organization] s care to go directly to his or her home, the complete and reconciled list of medications is provided to the [patient] s known primary care provider, the original referring provider, or a known next provider of service. Note: When the next provider of service is unknown or when no known formal relationship is planned with a next provider, giving the [patient] and, as needed, the family the list of reconciled medications is sufficient. 1. The patient s most current reconciled medication list is communicated to the next provider of service, either within or outside the hospital. The communication between providers is documented. 2. At the time of transfer, the transferring hospital informs the next provider of service how to obtain clarification on the list of reconciled medications. (Joint Commission National Patient Safety Goals, 2009) NPSG When a [patient] leaves the [organization] s care, a complete and reconciled list of the [patient] s medications is provided directly to the [patient] and, as needed, the family, and the list is explained to the [patient] and/or family. 1. When the patient leaves the hospital s care, the current list of reconciled medications is provided and explained to the patient and, as needed, the family. This interaction is documented. Note: Patients and families are reminded to discard old lists and to update any records with all medication providers or retail pharmacies. (Joint Commission National Patient Safety Goals, 2009) NPSG Maintain and communicate accurate patient medication information. (Joint Commission National Patient Safety Goals, 2012) Rationale for NPSG There is evidence that medication discrepancies can affect patient outcomes. Medication reconciliation is intended to identify and resolve discrepancies it is a process of comparing the medications a patient is taking (and should be taking) with newly ordered medications. The comparison addresses duplications, omissions, and interactions, and the need to continue current medications. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future. Elements of Performance for NPSG Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications. Note 1: Current medications include those taken at scheduled times and those taken on an as needed basis. See the Glossary for a definition of medications. Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP. 2. Define the types of medication information to be collected in non 24-hour settings and different patient circumstances. Note 1: Examples of non 24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings. Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose. 3. Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 10

11 hospital in order to identify and resolve discrepancies. Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by the hospital, does the comparison. (See also HR , EP 1) 4. Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose). Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications. For more information about communications to other providers of care when the patient is discharged or transferred, refer to Standard PC Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter. Note: Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on patient education on medications, refer to Standards MM , PC , and PC ) (Joint Commission National Patient Safety Goals, 2012) Safe Practice 17: Medication Reconciliation The healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care. (NQF Safe Practices for Better Healthcare 2010 Update) -Educate clinicians upon hire on the importance of medication reconciliation; frequency of ongoing education is based on the risk of noncompliance and adverse drug events as determined by the organization. -Providers receiving the patient in a transition of care should check the medication reconciliation list to make sure it is accurate and in concert with any new medications that are ordered/prescribed. -The list should include the full range of medications as defined by accrediting organizations such as The Joint Commission. At a minimum, the list should include the following: prescription medications; sample medications; vitamins; nutriceuticals; overthe-counter drugs; complementary and alternative medications; radioactive medications; respiratory therapy-related medications; parenteral nutrition; blood derivatives; intravenous solutions (plain or with additives); investigational agents; and any product designated by the Food and Drug Administration (FDA) as a drug. -At the time the patient enters the organization or is admitted, a complete list of medications the patient is taking at home (including dose, route, and frequency) is created and documented. The patient, and family, as needed, are involved in creating this list. -The medications ordered for the patient while under the care of the organization are compared to those on the list created at the time of entry to the organization or admission. According to The Joint Commission s FAQ, organizations should keep two lists during the hospitalization. The home medications list should be maintained unchanged and available for subsequent use in the reconciliation process. The list of the patient s current medications while in the hospital is a dynamic document that will require updating whenever changes are made to the patient s medication regimen. Both lists should be considered whenever reconciliation is carried out. The reason for referring to the home medication list is that some home medications may be held when a patient is admitted or goes to surgery. They may need to be resumed upon transfer to a different level of care, return from the operating room, or at discharge. -Any discrepancies (i.e., omissions, duplications, adjustments, deletions, additions) are reconciled and documented while the patient is under the care of the organization. -When the patient s care is transferred within the organization (e.g., from the ICU to a floor), the current provider(s) inform(s) the receiving provider(s) about the up-to-date reconciled medication list and documents the communication. -The patient s most current reconciled medication list is communicated to the next provider of service, either within or outside the organization. The communication between providers is documented. -At the time of transfer, the transferring organization informs the next provider of service of how to obtain clarification on the list of reconciled medications. -When the patient leaves the organization s care, the current list of reconciled medications is provided to the patient, and family, as needed, and is explained to the patient and/or family, and the interaction is documented. [Jack, 2009: Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009 Feb 3;150(3): ] -In settings where medications are used minimally, or are prescribed for a short duration, modified medication reconciliation See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 11

12 processes are performed: The organization obtains and documents an accurate list of the patient s current medications and known allergies in order to safely prescribe any setting-specific medications (e.g., IV contrast, local anesthesia, antibiotics) and to assess for potential allergic or adverse drug reactions. If no changes are made to the patient s current medication list, or when only short-term medications (e.g., a preprocedure medication or a short-term course of an antibiotic) will be prescribed, the patient, and family, as needed, are provided with a list containing the short-term medication additions that the patient will continue after leaving the organization. In these settings, there is a complete, documented medication reconciliation process when: Any new long-term (chronic) medications are prescribed. There is a prescription change for any of the patient s current known long-term medications. The patient is required to be subsequently admitted to an organization from these settings for ongoing care. When a complete, documented, medication reconciliation is required in any of these settings, the complete list of reconciled medications is provided to the patient and the patient s family, as needed, and to the patient s known primary care provider or original referring provider, or a known next provider of service. (NQF Safe Practices for Better Healthcare 2010 Update) The discharge process must effectively address the patient s needs for continuing care and treatment and must effectively communicate this information to patients and responsible caregivers in a timely fashion. [Greenwald JL, Denham CRD, Jack BW. The Hospital Discharge: A Review of a Care Transition with a High Potential for Errors and Highlights of a Re-Engineered Discharge Process. J Patient Saf 2007 Jun;3(2):97-106] As part of this process, hospitals should identify the critical components of the discharge plan that pose the greatest patient safety risks; typically, these exist in the area of medication reconciliation. [Williams TA, Leslie GD, Elliott N, et al. Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU. J Nurs Care Qual 2009 Jul 3 (Epub ahead of print)] (NQF Safe Practices for Better Healthcare 2010 Update) 1c.17 Clinical Practice Guideline Citation: Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, Weiss KB, Williams MV. Transitions of Care Consensus Policy Statement: American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med 2009 Apr 3. Institute for Healthcare Improvement. Reconcile medications at all transition points: Reconcile discharge orders with the nursing medication administration record. Available at: Also available: How-to Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation. Cambridge, MA: Institute for Healthcare Improvement; Joint Commission on Accreditation of Healthcare Organizations Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission Resources, Inc. Joint Commission on Accreditation of Healthcare Organizations. National Patient Safety Goals Effective January 1, Hospital Accreditation Program. Oakbrook Terrace, IL: Joint Commission Resources, Inc. National Quality Forum (NQF). Safe Practices for Better Healthcare 2010 Update: A Consensus Report. Washington, DC: NQF; c.18 National Guideline Clearinghouse or other URL: 1c.19 Grading of Strength of Guideline Recommendation. Has the recommendation been graded? No 1c.20 If guideline recommendation graded, identify the entity that graded the evidence including balance of representation and any disclosures regarding bias: 1c.21 System Used for Grading the Strength of Guideline Recommendation: Other 1c.22 If other, identify and describe the grading scale with definitions: The guideline recommendations were not graded. 1c.23 Grade Assigned to the Recommendation: N/A 1c.24 Rationale for Using this Guideline Over Others: It is the PCPI policy to use guidelines, which are evidence-based, applicable to physicians and other health-care providers, and developed by a national specialty organization or government agency. In addition, the PCPI has now expanded what is acceptable as the evidence base for measures to include documented quality See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 12

13 improvement (QI) initiatives or implementation projects that have demonstrated improvement in quality of care. Based on the NQF descriptions for rating the evidence, what was the developer s assessment of the quantity, quality, and consistency of the body of evidence? 1c.25 Quantity: Moderate 1c.26 Quality: Moderate1c.27 Consistency: Moderate Was the threshold criterion, Importance to Measure and Report, met? (1a & 1b must be rated moderate or high and 1c yes) Yes No Provide rationale based on specific subcriteria: For a new measure if the Committee votes NO, then STOP. For a measure undergoing endorsement maintenance, if the Committee votes NO because of 1b. (no opportunity for improvement), it may be considered for continued endorsement and all criteria need to be evaluated. 2. RELIABILITY & VALIDITY - SCIENTIFIC ACCEPTABILITY OF MEASURE PROPERTIES Extent to which the measure, as specified, produces consistent (reliable) and credible (valid) results about the quality of care when implemented. (evaluation criteria) Measure testing must demonstrate adequate reliability and validity in order to be recommended for endorsement. Testing may be conducted for data elements and/or the computed measure score. Testing information and results should be entered in the appropriate field. Supplemental materials may be referenced or attached in item 2.1. See guidance on measure testing. S.1 Measure Web Page (In the future, NQF will require measure stewards to provide a URL link to a web page where current detailed specifications can be obtained). Do you have a web page where current detailed specifications for this measure can be obtained? Yes S.2 If yes, provide web page URL: 2a. RELIABILITY. Precise Specifications and Reliability Testing: H M L I 2a1. Precise Measure Specifications. (The measure specifications precise and unambiguous.) 2a1.1 Numerator Statement (Brief, narrative description of the measure focus or what is being measured about the target population, e.g., cases from the target population with the target process, condition, event, or outcome): Patients or their caregiver(s) who received a reconciled medication list at the time of discharge including, at a minimum, medications in the following categories: Medications to be TAKEN by patient: - Continued* Medications prescribed before inpatient stay that patient should continue to take after discharge, including any change in dosage or directions AND - New* Medications started during inpatient stay that are to be continued after discharge and newly prescribed medications that patient should begin taking after discharge * Prescribed dosage, instructions, and intended duration must be included for each continued and new medication listed Medications NOT to be Taken by patient: - Discontinued Medications taken by patient before the inpatient stay that should be discontinued or held after discharge, AND - Allergies and Adverse Reactions Medications administered during the inpatient stay that caused an allergic reaction or adverse event and were therefore discontinued 2a1.2 Numerator Time Window (The time period in which the target process, condition, event, or outcome is eligible for inclusion): At each discharge during measurement period See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 13

14 2a1.3 Numerator Details (All information required to identify and calculate the cases from the target population with the target process, condition, event, or outcome such as definitions, codes with descriptors, and/or specific data collection items/responses: Numerator Definitions: For the purposes of this measure, medications includes prescription, over-the-counter, and herbal products. Generic and proprietary names should be provided for each medication, when available. Given the complexity of the medication reconciliation process and variability across inpatient facilities in documentation of that process, this measure does not require that the medication list be organized under the taken/not taken headings OR the specified sub-categories, provided that the status of each medication (continued, new, or discontinued) is specified within the list AND any allergic reactions are identified. For EHR: This measure does not lend itself to a traditional specification for EHR reporting, where data elements, logic and clinical coding are identified to calculate the measure, due to the fact that every facility may have a different template for medication reconciliation and the information required for this measure is based on individualized patient information unique to one episode of care (ie, inpatient stay). We have provided guidance on how a facility should query the electronic health record for the information required for this measure. Producing the Reconciled Medication List Facilities that have implemented an EHR system should utilize their system to develop a standardized template for the Reconciled Medication List. A standardized template will ensure that all required data elements specified in the measure are included whenever a Reconciled Medication List is generated from the EHR. Each facility has the autonomy to customize the format of the Reconciled Medication List, based on clinical workflow, policies and procedures, and the patient population treated at the individual institution. Systematic External Reporting that the Reconciled Medication List was provided to patient In order to report, at the facility level, which of the discharged patients have received a Reconciled Medication List, a discrete data field and code indicating the patient received a reconciled medication list at discharge may be needed in the EHR. Each facility should determine the most effective way to identify whether or not the patient received the reconciled medication list. Transmitting the Reconciled Medication List This performance measure does not require that the Reconciled Medication List be transmitted to the next provider(s) of care. However, if it is transmitted to the next provider(s) of care, it should be done so in accordance with established approved standards for interoperability. The ONC Health IT Standards Committee (HITSC) has recommended that certain vocabulary standards are used for quality measure reporting, in accordance with the Quality Data Model, developed by the National Quality Forum. RxNorm has been named as the recommended vocabulary for medications and can be used to identify the medications to which the allergies exist. Allergies (non-substance) and Adverse Events to medications should be expressed using SNOMED-CT. The use of industry standards for the transmission of the Reconciled Medication List information will ensure that the information can be received into the destination EHR. For Claims/Administrative: Numerator Action to be identified through medical record abstraction: See Sample Data Collection Tool attached. 2a1.4 Denominator Statement (Brief, narrative description of the target population being measured): All patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care. Time Window: Each time a patient is discharged from an inpatient facility 2a1.5 Target Population Category (Check all the populations for which the measure is specified and tested if any): Adult/Elderly Care 2a1.6 Denominator Time Window (The time period in which cases are eligible for inclusion): See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 14

15 Each discharge during 12 consecutive month measurement period 2a1.7 Denominator Details (All information required to identify and calculate the target population/denominator such as definitions, codes with descriptors, and/or specific data collection items/responses): For EHR: Eligible discharges for the denominator should be identified through the Admission, Discharge, Transfer (ADT) system, or from another electronic system where this information is stored. For Claims/Administrative: Identify patients discharged from inpatient facility using the following: UB-04 (Form Locator 04 - Type of Bill): 0111 (Hospital, Inpatient, Admit through Discharge Claim) 0121 (Hospital, Inpatient - Medicare Part B only, Admit through Discharge Claim) 0114 (Hospital, Inpatient, Last Claim) 0124 (Hospital, Inpatient - Medicare Part B only, Interim-Last Claim) 0211 (Skilled Nursing-Inpatient, Admit through Discharge Claim) 0214 (Skilled Nursing-Inpatient, Interim, Last Claim) 0221 (Skilled Nursing-Inpatient, Medicare Part B only, Admit through Discharge Claim) 0224 (Skilled Nursing- Interim, Last Claim) 0281 (Skilled Nursing-Swing Beds, Admit through Discharge Claim) 0284 (Skilled Nursing-Swing Beds, Interim, Last Claim) AND Discharge Status (Form Locator 17) 01 (Discharged to home care or self care (routine discharge) 02 (Discharged/transferred to a short term general hospital for inpatient care) 03 (Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care) 04 (Discharged/transferred to an intermediate care facility) 05 Discharged/transferred to a designated cancer center or children s hospital 06 (Discharged/transferred to home under care of organized home health service org. in anticipation of covered skilled care) 43 (Discharged/transferred to a federal health care facility) 50 (Hospice home) 51 (Hospice - medical facility (certified) providing hospice level of care) 61 (Discharged/transferred to hospital-based Medicare approved swing bed) 62 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital) 63 (Discharged/transferred to a Medicare certified long term care hospital (LTCH)) 64 (Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare) 65 (Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital) 66 (Discharged/transferred to a Critical Access Hospital (CAH)) 70 (Discharged/transferred to another type of health care institution not defined elsewhere in this code list) OR UB-04 (Form Locator 04 - Type of Bill): 0131 (Hospital Outpatient, Admit through Discharge Claim) 0134 (Hospital Outpatient, Interim, Last Claim) AND UB-04 (Form Locator 42 - Revenue Code): 0762 (Hospital Observation) 0490 (Ambulatory Surgery) 0499 (Other Ambulatory Surgery) AND Discharge Status (Form Locator 17) 01 (Discharged to home care or self care (routine discharge) 02 (Discharged/transferred to a short term general hospital for inpatient care) 03 (Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care) See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 15

16 04 (Discharged/transferred to an intermediate care facility) 05 Discharged/transferred to a designated cancer center or children s hospital 06 (Discharged/transferred to home under care of organized home health service org. in anticipation of covered skilled care) 43 (Discharged/transferred to a federal health care facility) 50 (Hospice home) 51 (Hospice - medical facility (certified) providing hospice level of care) 61 (Discharged/transferred to hospital-based Medicare approved swing bed) 62 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital) 63 (Discharged/transferred to a Medicare certified long term care hospital (LTCH)) 64 (Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare) 65 (Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital) 66 (Discharged/transferred to a Critical Access Hospital (CAH)) 70 (Discharged/transferred to another type of health care institution not defined elsewhere in this code list) 2a1.8 Denominator Exclusions (Brief narrative description of exclusions from the target population): Patients who died Patients who left against medical advice (AMA) or discontinued care 2a1.9 Denominator Exclusion Details (All information required to identify and calculate exclusions from the denominator such as definitions, codes with descriptors, and/or specific data collection items/responses): For Claims/Administrative Data: UB-04 (Form Locator 17 - Discharge Status): 07 Left against medical advice or discontinued care 20 Expired 40 Expired at home 41 Expired in a medical facility 42 Expired-place unknown 2a1.10 Stratification Details/Variables (All information required to stratify the measure results including the stratification variables, codes with descriptors, definitions, and/or specific data collection items/responses ): We encourage the results of this measure to be stratified by race, ethnicity, gender, and primary language, and have included these variables as recommended data elements to be collected. 2a1.11 Risk Adjustment Type (Select type. Provide specifications for risk stratification in 2a1.10 and for statistical model in 2a1.13): No risk adjustment or risk stratification 2a1.12 If "Other," please describe: 2a1.13 Statistical Risk Model and Variables (Name the statistical method - e.g., logistic regression and list all the risk factor variables. Note - risk model development should be addressed in 2b4.): No risk adjustment or risk stratification. 2a Detailed Risk Model Available at Web page URL (or attachment). Include coefficients, equations, codes with descriptors, definitions, and/or specific data collection items/responses. Attach documents only if they are not available on a webpage and keep attached file to 5 MB or less. NQF strongly prefers you make documents available at a Web page URL. Please supply login/password if needed: 2a Type of Score: Rate/proportion 2a1.19 Interpretation of Score (Classifies interpretation of score according to whether better quality is associated with a higher score, a lower score, a score falling within a defined interval, or a passing score): Better quality = Higher score See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 16

17 2a1.20 Calculation Algorithm/Measure Logic(Describe the calculation of the measure score as an ordered sequence of steps including identifying the target population; exclusions; cases meeting the target process, condition, event, or outcome; aggregating data; risk adjustment; etc.): To calculate performance rates: 1) Find the patients who meet the initial patient population (ie, the general group of patients that the performance measure is designed to address). 2) From the patients within the initial patient population criteria, find the patients who qualify for the denominator (ie, the specific group of patients for inclusion in a specific performance measure based on defined criteria). Note: in some cases the initial patient population and denominator are identical. For the purpose of this measure, a patient can qualify for the measure multiple times during the measurement period if they have multiple inpatient discharges. 3) From the patients within the denominator, find the patients who qualify for the Numerator (ie, the group of patients in the denominator for whom a process or outcome of care occurs). Validate that the number of patients in the numerator is less than or equal to the number of patients in the denominator 4) From the patients who did not meet the numerator criteria, determine if the physician has documented that the patient meets any criteria for denominator exception when exceptions have been specified [for this measure: Patients who died OR Patients who left against medical advice (AMA) or discontinued care]. If the patient meets any exception criteria, they should be removed from the denominator for performance calculation. --Although the exception cases are removed from the denominator population for the performance calculation, the number of patients with valid exceptions should be calculated and reported along with performance rates to track variations in care and highlight possible areas of focus for QI. If the patient does not meet the numerator and a valid exception is not present, this case represents a quality failure. 2a Calculation Algorithm/Measure Logic Diagram URL or attachment: 2a1.24 Sampling (Survey) Methodology. If measure is based on a sample (or survey), provide instructions for obtaining the sample, conducting the survey and guidance on minimum sample size (response rate): The measure does not require sampling or a survey. 2a1.25 Data Source (Check all the sources for which the measure is specified and tested). If other, please describe: Administrative claims, Electronic Clinical Data : Electronic Health Record, Paper Records 2a1.26 Data Source/Data Collection Instrument (Identify the specific data source/data collection instrument, e.g. name of database, clinical registry, collection instrument, etc.): See attached data collection tool. 2a Data Source/data Collection Instrument Reference Web Page URL or Attachment: 2a Data Dictionary/Code Table Web Page URL or Attachment: Attachment 0646_AMA PCPI_MEDRECONCILIATION_DataCollectionTool.pdf 2a1.33 Level of Analysis (Check the levels of analysis for which the measure is specified and tested): Facility, Integrated Delivery System 2a Care Setting (Check all the settings for which the measure is specified and tested): Ambulatory Care : Ambulatory Surgery Center (ASC), Hospital/Acute Care Facility, Post Acute/Long Term Care Facility : Nursing Home/Skilled Nursing Facility, Post Acute/Long Term Care Facility : Rehabilitation See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 17

18 2a2. Reliability Testing. (Reliability testing was conducted with appropriate method, scope, and adequate demonstration of reliability.) 2a2.1 Data/Sample (Description of the data or sample including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included): Refer to the validity section for a description of the data sample for our EHR testing project. 2a2.2 Analytic Method (Describe method of reliability testing & rationale): Refer to the validity section for a description of the analytic methods for our EHR testing project. 2a2.3 Testing Results (Reliability statistics, assessment of adequacy in the context of norms for the test conducted): Refer to the validity section for the testing results for our EHR testing project. 2b. VALIDITY. Validity, Testing, including all Threats to Validity: H M L I 2b1.1 Describe how the measure specifications (measure focus, target population, and exclusions) are consistent with the evidence cited in support of the measure focus (criterion 1c) and identify any differences from the evidence: The evidence cited for this measure is directly related to medication reconciliation for all ages, during transitions of care from inpatient to outpatient settings. There are no differences from the measure focus, target population, or exclusions. 2b2. Validity Testing. (Validity testing was conducted with appropriate method, scope, and adequate demonstration of validity.) 2b2.1 Data/Sample (Description of the data or sample including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included): EHR Measure Validity AMA-PCPI Testing Project o This project identified a sample of patients taken from one multi-specialty, medium-sized health practice in Southeast Texas. o This health practice has been designated by the NCQA as a Tier III Medical Home, and has made it a priority to create coordinated transitions in care across the continuum of care. o This proactive oversees approximately 7-8,000 hospital discharges per year. o Measure implementation began in July of o Manually abstracted sample included 100 patients from the inpatient setting. Face Validity The measures were pilot tested via focus group discussion and surveys in six Midwestern healthcare facilities between December 2009 and February Participants included front line caregivers as well as administrators and leadership. Approximately 65% of the 81 focus group participants also provided written surveys and feedback for analysis. 2b2.2 Analytic Method (Describe method of validity testing and rationale; if face validity, describe systematic assessment): EHR Measure Validity Data from a performance report for the measure automatically-generated from the EHR (designed to collect the necessary data elements to identify eligible cases and calculate the performance score) were compared to data elements found and scores calculated manually on visual inspection of the medical record by trained abstractors. Data analysis included: Percent agreement at the denominator, numerator, (exception - for those measures with exception) and the measure overall. Kappa statistic to ensure that agreement rates are not a phenomenon of chance Face Validity The clarity and face validity of measures was assessed using numeric surveys and focused discussion. The survey asked a panel consisting of 81 individuals including front line caregivers, administrators and leadership. See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 18

19 The aforementioned panel was asked to rate the following aspects of this measure: Clarity of Numerator Statement Clarity of Denominator Statement Clarity of Denominator Exclusions Overall Understanding of the Information in the Measure Specification Document The rating scale ranged from 1-5, where 1=Very Poor; 3=Average; 5=Very Good 2b2.3 Testing Results (Statistical results, assessment of adequacy in the context of norms for the test conducted; if face validity, describe results of systematic assessment): EHR Measure Validity Overall Reliability*: N, % Agreement, Kappa (95% Confidence Interval) 100, 91.00%, 0.81 ( ) This kappa shows an almost perfect level of agreement. *Visual inspection of the medical record compared to the automatically generated report of the data elements. Face Validity For this measure, 73% of respondents indicated a rating of 4 or 5 for the clarity of the numerator statement. Overall understanding of information in the measure specifications document received a score of 84% in the top 2 boxes for this measure. 95% of the 63 individuals providing feedback in the form of a numeric survey submitted a rating of 4 or 5 for the clarity of exceptions with a slightly lower percentage of respondents rating the clarity of denominator statements in the top 2 boxes (84%). POTENTIAL THREATS TO VALIDITY. (All potential threats to validity were appropriately tested with adequate results.) 2b3. Measure Exclusions. (Exclusions were supported by the clinical evidence in 1c or appropriately tested with results demonstrating the need to specify them.) 2b3.1 Data/Sample for analysis of exclusions (Description of the data or sample including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included): AMA-PCPI Testing Project o This project identified a sample of patients taken from a multi-specialty, medium-sized health practice in Southeast Texas. o This health practice has been designated by the NCQA as a Tier III Medical Home, and has made it a priority to create coordinated transitions in care across the continuum of care. o This proactive oversees approximately 7-8,000 hospital discharges per year. o Measure implementation began in July of o Manually abstracted sample included 100 patients from the inpatient setting. 2b3.2 Analytic Method (Describe type of analysis and rationale for examining exclusions, including exclusion related to patient preference): Data from an automatically-generated report from the EHR was compared to manual abstraction from patient records to calculate parallel forms reliability for the measure. Data analysis included: Percent agreement Kappa statistic to adjust for chance agreement 2b3.3 Results (Provide statistical results for analysis of exclusions, e.g., frequency, variability, sensitivity analyses): Overall Reliability: N, % Agreement, Kappa ( 95% Confidence Interval) See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 19

20 100, %, Kappa Not Calculable* * Kappa statistics cannot be calculated because of complete agreement. Confidence intervals cannot be calculated because to do so would involve dividing by zero which cannot be done. 2b4. Risk Adjustment Strategy. (For outcome measures, adjustment for differences in case mix (severity) across measured entities was appropriately tested with adequate results.) 2b4.1 Data/Sample (Description of the data or sample including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included): This measure is not risk adjusted. 2b4.2 Analytic Method (Describe methods and rationale for development and testing of risk model or risk stratification including selection of factors/variables): This measure is not risk adjusted. 2b4.3 Testing Results (Statistical risk model: Provide quantitative assessment of relative contribution of model risk factors; risk model performance metrics including cross-validation discrimination and calibration statistics, calibration curve and risk decile plot, and assessment of adequacy in the context of norms for risk models. Risk stratification: Provide quantitative assessment of relationship of risk factors to the outcome and differences in outcomes among the strata): This measure is not risk adjusted. 2b4.4 If outcome or resource use measure is not risk adjusted, provide rationale and analyses to justify lack of adjustment: As a process measure, no risk adjustment is necessary. 2b5. Identification of Meaningful Differences in Performance. (The performance measure scores were appropriately analyzed and discriminated meaningful differences in quality.) 2b5.1 Data/Sample (Describe the data or sample including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included): Highmark Quality Blue Hospital Pay-for-Performance Program 63 participating hospitals implemented Care Coordination measures as part of a defect-free care transitions bundle 2b5.2 Analytic Method (Describe methods and rationale to identify statistically significant and practically/meaningfully differences in performance): Highmark Quality Blue Hospital Pay-for-Performance Program Participant performance was assessed quarterly over the course of Fiscal Year b5.3 Results (Provide measure performance results/scores, e.g., distribution by quartile, mean, median, SD, etc.; identification of statistically significant and meaningfully differences in performance): Highmark Quality Blue Hospital Pay-for-Performance Program Participant performance on this measure, by quarter is as follows: FY 2011, Quarter 1: 35% FY 2011, Quarter 2: 42% FY 2011, Quarter 3: 50% 2b6. Comparability of Multiple Data Sources/Methods. (If specified for more than one data source, the various approaches result in comparable scores.) 2b6.1 Data/Sample (Describe the data or sample including number of measured entities; number of patients; dates of data; if a sample, characteristics of the entities included): AMA-PCPI Testing Project See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 20

21 o This project identified a sample of patients taken from one multi-specialty, medium-sized health practice in Southeast Texas. o This health practice has been designated by the NCQA as a Tier III Medical Home, and has made it a priority to create coordinated transitions in care across the continuum of care. o This proactive oversees approximately 7-8,000 hospital discharges per year. o Measure implementation began in July of o Manually abstracted sample included 100 patients from the inpatient setting. 2b6.2 Analytic Method (Describe methods and rationale for testing comparability of scores produced by the different data sources specified in the measure): Data from a performance report for the measure automatically-generated from the EHR (designed to collect the necessary data elements to identify eligible cases and calculate the performance score) were compared to data elements found and scores calculated manually on visual inspection of the medical record by trained abstractors. Data analysis included: Percent agreement at the denominator, numerator, (exception - for those measures with exception) and the measure overall. Kappa statistic to ensure that agreement rates are not a phenomenon of chance 2b6.3 Testing Results (Provide statistical results, e.g., correlation statistics, comparison of rankings; assessment of adequacy in the context of norms for the test conducted): Overall Reliability*: N, % Agreement, Kappa (95% Confidence Interval) 100, 91.00%, 0.81 ( ) This kappa shows an almost perfect level of agreement. *Visual inspection of the medical record compared to the automatically generated report of the data elements. 2c. Disparities in Care: H M L I NA (If applicable, the measure specifications allow identification of disparities.) 2c.1 If measure is stratified for disparities, provide stratified results (Scores by stratified categories/cohorts): We encourage the results of this measure to be stratified by race, ethnicity, gender, and primary language, and have included these variables as recommended data elements to be collected. 2c.2 If disparities have been reported/identified (e.g., in 1b), but measure is not specified to detect disparities, please explain: The PCPI advocates that performance measure data should, where possible, be stratified by race, ethnicity, and primary language to assess disparities and initiate subsequent quality improvement activities addressing identified disparities, consistent with recent national efforts to standardize the collection of race and ethnicity data. A 2008 NQF report endorsed 45 practices including stratification by the aforementioned variables.(1) A 2009 IOM report recommends collection of the existing Office of Management and Budget (OMB) race and Hispanic ethnicity categories as well as more fine-grained categories of ethnicity(referred to as granular ethnicity and based on one s ancestry) and language need (a rating of spoken English language proficiency of less than very well and one s preferred language for health-related encounters). (2) References: (1)National Quality Forum Issue Brief (No.10). Closing the Disparities Gap in Healthcare Quality with Performance Measurement and Public Reporting. Washington, DC: NQF, August (2)Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. March AHRQ Publication No EF. Agency for Healthcare Research and Quality, Rockville, MD. Available at: Accessed May 25, Supplemental Testing Methodology Information: See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 21

22 Steering Committee: Overall, was the criterion, Scientific Acceptability of Measure Properties, met? (Reliability and Validity must be rated moderate or high) Yes No Provide rationale based on specific subcriteria: If the Committee votes No, STOP 3. USABILITY Extent to which intended audiences (e.g., consumers, purchasers, providers, policy makers) can understand the results of the measure and are likely to find them useful for decision making. (evaluation criteria) C.1 Intended Purpose/ Use (Check all the purposes and/or uses for which the measure is intended): Public Reporting, Quality Improvement (Internal to the specific organization) 3.1 Current Use (Check all that apply; for any that are checked, provide the specific program information in the following questions): Public Reporting, Quality Improvement (Internal to the specific organization) 3a. Usefulness for Public Reporting: H M L I (The measure is meaningful, understandable and useful for public reporting.) 3a.1. Use in Public Reporting - disclosure of performance results to the public at large (If used in a public reporting program, provide name of program(s), locations, Web page URL(s)). If not publicly reported in a national or community program, state the reason AND plans to achieve public reporting, potential reporting programs or commitments, and timeline, e.g., within 3 years of endorsement: [For Maintenance If not publicly reported, describe progress made toward achieving disclosure of performance results to the public at large and expected date for public reporting; provide rationale why continued endorsement should be considered.] This measure was used in the Highmark Quality Blue Hospital Pay-for-Performance Program 2011, where 63 participating hospitals implemented Care Coordination measures as part of a defect-free care transitions bundle. The PCPI believes that the reporting of participation information is a beneficial first step on a trajectory toward the public reporting of performance results, which is appropriate since the measure has been tested and the reliability of the performance data has been validated. Continued NQF endorsement will facilitate our ongoing progress toward this public reporting objective. 3a.2.Provide a rationale for why the measure performance results are meaningful, understandable, and useful for public reporting. If usefulness was demonstrated (e.g., focus group, cognitive testing), describe the data, method, and results: The PCPI believes that the reporting of participation information is a beneficial first step on a trajectory toward the public reporting of performance results, which is appropriate since the measure has been tested and the reliability of the performance data has been validated. Continued NQF endorsement will facilitate our ongoing progress toward this public reporting objective. 3.2 Use for other Accountability Functions (payment, certification, accreditation). If used in a public accountability program, provide name of program(s), locations, Web page URL(s): This measure may be used in a Maintenance of Certification program. It was also used in the Highmark Quality Blue Hospital Pay-for-Performance Program 2011, where 63 participating hospitals implemented Care Coordination measures as part of a defect-free care transitions bundle. 3b. Usefulness for Quality Improvement: H M L I (The measure is meaningful, understandable and useful for quality improvement.) 3b.1. Use in QI. If used in quality improvement program, provide name of program(s), locations, Web page URL(s): [For Maintenance If not used for QI, indicate the reasons and describe progress toward using performance results for improvement]. All PCPI measures are suitable for use in quality improvement initiatives and are made freely available on the PCPI website and through the implementation efforts of medical specialty societies and other PCPI members. The PCPI strongly encourages the use of its measures in QI initiatives and seeks to provide information on such initiatives to PCPI members. See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 22

23 3b.2. Provide rationale for why the measure performance results are meaningful, understandable, and useful for quality improvement. If usefulness was demonstrated (e.g., QI initiative), describe the data, method and results: The PCPI believes that the use of PCPI measures in quality improvement initiatives is a beneficial way to gather scientific data with which to improve physician performance. This is appropriate since the measure has been tested and the reliability of the performance data has been validated. NQF endorsement will facilitate our ongoing progress toward this quality improvement objective. Overall, to what extent was the criterion, Usability, met? H M L I Provide rationale based on specific subcriteria: 4. FEASIBILITY Extent to which the required data are readily available, retrievable without undue burden, and can be implemented for performance measurement. (evaluation criteria) 4a. Data Generated as a Byproduct of Care Processes: H M L I 4a.1-2 How are the data elements needed to compute measure scores generated? (Check all that apply). Data used in the measure are: generated by and used by healthcare personnel during the provision of care, e.g., blood pressure, lab value, medical condition, Coded by someone other than person obtaining original information (e.g., DRG, ICD-9 codes on claims), Abstracted from a record by someone other than person obtaining original information (e.g., chart abstraction for quality measure or registry) 4b. Electronic Sources: H M L I 4b.1 Are the data elements needed for the measure as specified available electronically (Elements that are needed to compute measure scores are in defined, computer-readable fields): ALL data elements in electronic health records (EHRs) 4b.2 If ALL data elements are not from electronic sources, specify a credible, near-term path to electronic capture, OR provide a rationale for using other than electronic sources: 4c. Susceptibility to Inaccuracies, Errors, or Unintended Consequences: H M L I 4c.1 Identify susceptibility to inaccuracies, errors, or unintended consequences of the measurement identified during testing and/or operational use and strategies to prevent, minimize, or detect. If audited, provide results: We are not aware of any unintended consequences related to this measurement. 4d. Data Collection Strategy/Implementation: H M L I A.2 Please check if either of the following apply (regarding proprietary measures): 4d.1 Describe what you have learned/modified as a result of testing and/or operational use of the measure regarding data collection, availability of data, missing data, timing and frequency of data collection, sampling, patient confidentiality, time and cost of data collection, other feasibility/implementation issues (e.g., fees for use of proprietary measures): This measure was found to be reliable and feasible for implementation. Overall, to what extent was the criterion, Feasibility, met? H M L I Provide rationale based on specific subcriteria: OVERALL SUITABILITY FOR ENDORSEMENT Does the measure meet all the NQF criteria for endorsement? Yes No Rationale: If the Committee votes No, STOP. If the Committee votes Yes, the final recommendation is contingent on comparison to related and competing measures. See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 23

24 5. COMPARISON TO RELATED AND COMPETING MEASURES If a measure meets the above criteria and there are endorsed or new related measures (either the same measure focus or the same target population) or competing measures (both the same measure focus and the same target population), the measures are compared to address harmonization and/or selection of the best measure before a final recommendation is made. 5.1 If there are related measures (either same measure focus or target population) or competing measures (both the same measure focus and same target population), list the NQF # and title of all related and/or competing measures: 0097 : Medication Reconciliation 0554 : Medication Reconciliation Post-Discharge 5a. Harmonization 5a.1 If this measure has EITHER the same measure focus OR the same target population as NQF-endorsed measure(s): Are the measure specifications completely harmonized? No 5a.2 If the measure specifications are not completely harmonized, identify the differences, rationale, and impact on interpretability and data collection burden: Our measure has a broader target population since the two measures above are for the geriatric population. Additionally, our measure has much greater specificity in regards to components of the reconciled medication list, which our measure development panel agreed would have a greater impact on improving transitional care and reducing medication errors, adverse drug events, patient harm and hospital readmissions. 5b. Competing Measure(s) 5b.1 If this measure has both the same measure focus and the same target population as NQF-endorsed measure(s): Describe why this measure is superior to competing measures (e.g., a more valid or efficient way to measure quality); OR provide a rationale for the additive value of endorsing an additional measure. (Provide analyses when possible): N/A CONTACT INFORMATION Co.1 Measure Steward (Intellectual Property Owner): American Medical Association - Physician Consortium for Performance Improvement, 515 N. State St., Chicago, Illinois, Co.2 Point of Contact: Mark S., Antman, DDS, MBA, Director, Measure Development Operations Performance Improvement, [email protected], Co.3 Measure Developer if different from Measure Steward: American Medical Association - Physician Consortium for Performance Improvement, 515 N. State St., Chicago, Illinois, Co.4 Point of Contact: Katherine, Ast, MSW, LCSW, Policy Analyst, Measure Development Operations Performance Improvement, [email protected], Co.5 Submitter: Katherine, Ast, MSW, LCSW, Policy Analyst, Measure Development Operations Performance Improvement, [email protected], , American Medical Association - Physician Consortium for Performance Improvement Co.6 Additional organizations that sponsored/participated in measure development: ABIM Foundation American College of Physicians Society of Hospital Medicine Co.7 Public Contact: Mark S., Antman, DDS, MBA, Director, Measure Development Operations Performance Improvement, [email protected], , American Medical Association - Physician Consortium for Performance Improvement ADDITIONAL INFORMATION See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 24

25 Workgroup/Expert Panel involved in measure development Ad.1 Provide a list of sponsoring organizations and workgroup/panel members names and organizations. Describe the members role in measure development. PCPI measures are developed through cross-specialty, multi-disciplinary work groups. All medical specialties and other health care professional disciplines participating in patient care for the clinical condition or topic under study must be equal contributors to the measure development process. In addition, the PCPI strives to include on its work groups individuals representing the perspectives of patients, consumers, private health plans, and employers. This broad-based approach to measure development ensures buy-in on the measures from all stakeholders and minimizes bias toward any individual specialty or stakeholder group. All work groups have at least two co-chairs who have relevant clinical and/or measure development expertise and who are responsible for ensuring that consensus is achieved and that all perspectives are voiced. Robert M. Palmer, MD, MPH (Co-Chair) (Geriatrics/Gerontology) Mark V. Williams, MD, FACP (Co-Chair) (Hospital medicine) Dennis M. Beck, MD, FACEP (Emergency medicine) Judith S. Black, MD, MHA (Blue Cross and Blue Shield Association) Caroline Blaum, MD (Geriatrics) Clair M. Callan, MD, MBA, CPE (American College of Physician Executives) Jayne Hart Chambers, MBA (Federation of American Hospitals) Steven Chen, MD, MBA (Surgical oncology) Kenneth D. Coburn, MD, MPH (Health Quality Partners) Mirean Fisher Coleman, MSW, LICSW, CT (National Association of Social Workers) Sydney Dy, MD, MSc (Hospice and palliative medicine) Scott Endsley, MD, MSc (Health Services Advisory Group) David A. Etzioni, MD, MSHS (Colon and rectal surgery) Beth Feldpush, MPH (American Hospital Association) Rita Munley Gallagher, PhD, RN (American Nurses Association) G. Scott Gazelle, MD, MPH, PhD (Radiology) Robert W. Gilmore, MD (Clinical surgery) Eric S. Holmboe, MD, FACP (Internal medicine) Mary Ann Kliethermes, B.S., Pharm.D. (American Society of Health System Pharmacists) James E. Lett, II, MD (American Medical Directors Association) Janet R. Maurer, MD, MBA, FCCP (Pulmonology) Andie Melendez, RN, MSN, HTPC (Academy of Medical-Surgical Nurses) Donise Mosebach, RN, MS, CEN (The Joint Commission) Michael O Dell, MD, MSHA, FAAFP (Family medicine) Eric D. Peterson, MD, MPH, FAHA, FACC (American Heart Association/Cardiology) Mark Redding MD. FAAP (Pediatrics) Michael Ries, MD, MBA, FCCM (Critical care medicine) Hilary C. Siebens, MD (Physical medicine and rehabilitation) Janet (Jesse) Sullivan, MD (National Transitions of Care Coalition) Randal J. Thomas, MD, MS, FACC, FAHA, FACP, FAACVPR (Cardiology) Christopher Tompkins, PhD (Brandeis University) Robert Wears, MD, FACEP (Emergency medicine) ABIM Foundation Daniel B. Wolfson, MHSA American College of Physicians Vincenza Snow, MD, FACP Society of Hospital Medicine Jill Epstein, MA See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 25

26 PCPI Consultants Rebecca Kresowik Timothy Kresowik, MD National Committee for Quality Assurance Liaison Aisha Tenea Pittman, MPH American Medical Association Mark Antman, DDS, MBA Heidi Bossley, MSN, MBA Kerri Fei, MSN, RN JoeAnn Jackson, MJ Kendra Hanley, MS Karen Kmetik, PhD Joanne G. Schwartzberg, MD Patricia Sokol, RN, JD Chyna Wilcoxson Ad.2 If adapted, provide title of original measure, NQF # if endorsed, and measure steward. Briefly describe the reasons for adapting the original measure and any work with the original measure steward: Measure Developer/Steward Updates and Ongoing Maintenance Ad.3 Year the measure was first released: 2009 Ad.4 Month and Year of most recent revision: 12, 2011 Ad.5 What is your frequency for review/update of this measure? See Ad.9. Ad.6 When is the next scheduled review/update for this measure? 12, 2012 Ad.7 Copyright statement: Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for Performance Improvement (the Consortium), are intended to facilitate quality improvement activities by physicians. These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for all potential applications. The Consortium encourages the testing and evaluation of its Measures. Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be responsible for any use of these Measures. THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND 2009 American Medical Association. All Rights Reserved Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. CPT contained in the Measures specifications is copyright 2008 American Medical Association. See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 26

27 Ad.8 Disclaimers: Ad.9 Additional Information/Comments: Coding/Specifications updates occur annually. The PCPI has a formal measurement review process that stipulates regular (usually on a three-year cycle, when feasible) review of the measures. The process can also be activated if there is a major change in scientific evidence, results from testing or other issues are noted that materially affect the integrity of the measure. Date of Submission (MM/DD/YY): 01/09/2012 See Guidance for Definitions of Rating Scale: H=High; M=Moderate; L=Low; I=Insufficient; NA=Not Applicable 27